What is the treatment for a symptomatic yeast infection in the urine, specifically for a patient with yeast on urine culture?

Treatment for Symptomatic Yeast Infection in Urine

For symptomatic Candida cystitis, oral fluconazole at a dosage of 200 mg (3 mg/kg) daily for 2 weeks is the recommended first-line treatment. 1

Treatment Algorithm Based on Infection Site and Candida Species

1. Candida Cystitis (Lower Urinary Tract)

• First-line therapy:

  • Fluconazole-susceptible species: Oral fluconazole 200 mg daily for 2 weeks 1

• Alternative therapies (for fluconazole-resistant species):

  • For C. glabrata: Amphotericin B deoxycholate (AmB-d) 0.3-0.6 mg/kg daily for 1-7 days, with or without oral flucytosine 25 mg/kg 4 times daily 1
  • For C. glabrata: Monotherapy with oral flucytosine 25 mg/kg 4 times daily for 2 weeks 1
  • For C. krusei: AmB-d 0.3-0.6 mg/kg daily for 1-7 days 1
  • For refractory fluconazole-resistant infections: AmB-d bladder irrigation 1

2. Candida Pyelonephritis (Upper Urinary Tract)

• First-line therapy:

  • Fluconazole-susceptible species: Oral fluconazole 200-400 mg daily for 2 weeks 1

• Alternative therapies (for fluconazole-resistant species):

  • AmB-d 0.5-0.7 mg/kg daily with or without flucytosine 25 mg/kg 4 times daily for 2 weeks 1
  • Flucytosine alone 25 mg/kg 4 times daily for 2 weeks 1

3. Fungus Balls

• Surgical intervention is strongly recommended 1
• Systemic antifungal therapy as above based on susceptibility
• If access to the renal collecting system is available, irrigation with AmB-d (50 mg/L sterile water) as adjunct therapy 1

Important Considerations

Diagnostic Approach

• Evaluate candiduria in clinical context to differentiate colonization from infection 1
• Symptoms of UTI (dysuria, frequency, urgency) suggest true infection rather than colonization
• Imaging (ultrasound or CT) may help identify structural abnormalities, hydronephrosis, or fungus balls 1

Management Principles

1. Eliminate predisposing factors when possible:

   • Remove or replace indwelling catheters 2
   • Discontinue unnecessary antibiotics 3
   • Address urinary tract obstruction if present 1

2. Antifungal selection considerations:

   • Urinary concentration of the drug is critical for effectiveness 1
   • Fluconazole achieves high urinary concentrations and is well-tolerated 2, 3
   • Echinocandins and other azoles (besides fluconazole) generally should not be used due to poor urinary concentrations 4, 3

3. Special populations:

   • For candiduria with suspected disseminated candidiasis: Treat as for candidemia 1
   • For high-risk patients (neutropenic, low-birth-weight infants): More aggressive approach is warranted even if asymptomatic 1, 2

Common Pitfalls and Caveats

1. Treating asymptomatic candiduria: Generally not recommended unless the patient is at high risk (neutropenic, very low birth weight infant) or undergoing urologic procedures 1, 2

2. Inappropriate antifungal selection: Newer azoles (voriconazole, posaconazole) and echinocandins (caspofungin, micafungin, anidulafungin) achieve poor urinary concentrations and should generally be avoided for urinary tract infections 1, 4

3. Failure to address underlying factors: Not removing catheters or addressing obstruction can lead to treatment failure despite appropriate antifungal therapy 1

4. Inadequate treatment duration: Shorter courses may lead to relapse; complete the full recommended duration 1

5. Overlooking resistant species: C. glabrata and C. krusei often require alternative treatments to fluconazole 1